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3 Tactics to Improve Population Health in Home Care

Why the future of home care must focus on population health

Across the healthcare industry, leaders are tirelessly thinking about how to solve “gaps” in care—access, staffing, technology, prescriptions—while navigating regulatory policies that can hinder or help their efforts.

Taking steps to close gaps and successfully address the Triple Aim is an endless effort. But progress is real.

Judy Walsh, Regional Director of Population Health at Constellation Health Services, is passionate about addressing the gap in home-based delivery of care across the continuum, recognizing the urgency.

“Even before COVID came along, we knew that the number of people turning 65 and in need of care will grow exponentially over the next 20 years,” she says. “​​As of today, 46 million patients are over 65. By 2050, that’s going to be 90 million.”

Though nursing school enrollment increased during the pandemic, the number isn’t on a trajectory with the upward trend of aging Americans. Additionally, nurse faculty is expected to shrink by 25% due to pandemic burnout and other reasons that leave a gap in training. A February 2022 survey of nurses indicated that 90% would shortly leave their jobs—70% of those are nurses with 15 years of experience. 

As the ratio of patients-to-care professionals widens, technology has become the most scalable option to increase available care. Health care providers who have accepted this reality have pivoted with great success. Three years ago, Constellation—a Northeast-based home health agency—added its population health division to ensure patients could remain safely at home and avoid hospitalizations.

Below, Walsh discusses three innovative tactics that Constellation uses to address the population health crisis through the lens of home-based care.

No. 1—Build a Tech-Forward, Service-First Population Health Model

Healthcare providers who can manage care with technology have proven to be more efficient, capable, and responsive. Unlike most home health providers, Constellation incorporated a next-level population health model combining technology, Nurse Practitioner (NP) advanced oversight, and in-person service to reduce readmissions. 

Constellation’s Population Health division is responsible for identifying and managing high-risk patients and ensuring that all patients receive the interventions they need. This team works in conjunction with our home care team, and supports this team by coordinating virtual patient visits with a Nurse Practitioner, providing remote monitoring devices to the patient, and communicating with the Primary Care Providers (PCP) or other community care providers when our patients exhibit out of range vital sign readings and/or worsening symptoms. These processes and strategies enable us to manage our patient population so that they can stay safely at home.

“We found that the patients receiving care as part of this model were returning to the hospital at a much lower rate,” Walsh says. “Over the last two years, readmissions for this subset of patients have been in single digits whereas the rest of the country and most agencies across the country are readmitting 17% to 24% of their patients.”

As Walsh notes, incorporating technology into care is not a one-size-fits-all solution. Prioritizing the patient experience has to be front and center. The model must take patients’ concerns and fears into consideration. 

“If we don’t listen to patients,” she says, “when they’re telling us what they can and can’t do with technology, we’re not going to take care of them successfully.” 


No. 2—Invest in the Social Component of Population Health 

One of the byproducts of healthcare providers leaning into technology is a gap in access. It comes down to technology has and have nots. 

Equity of care will not be solved overnight without private investment. 

“Many providers don’t invest in the technology needed for the patient to succeed,” Walsh says. “Though the Centers for Medicare and Medicaid Services are taking steps, there are a lot of families and patients who might find it difficult to obtain technology, especially if they rely on an individual caregiver or don’t have access to a tech-forward agency. There’s going to be a big gap in care.”

Even if it is an “out-of-pocket” expense for home health agencies, investing in technology that can significantly improve population health in the community is a game-changer. 

“I am really proud that Constellation has invested in this technology, which is not considered a necessity or reimbursed by payers,” Walsh says. “As an industry, as companies, as compassionate care professionals, we will have to figure out how to make care accessible to all patients. That’s how we look at it at Constellation, and that’s the direction we’re taking.”

Another social component is time—investing in the time to train staff around technology utilization. The right tools and resources offer relief from pandemic whiplash (i.e., more demands, staffing shortages, etc.) by making the work manageable and scalable. When a care team is taken care of, patients are, too.

“We always ask, ‘Are we providing everything that we can without making the patient leave the house?’ Answering that question requires arming our team with resources and celebrating a solution-oriented mindset,” Walsh says.

No. 3—Responsiveness Must Be Prioritized

A matter of minutes is all it takes for a patient episode to occur and escalate into an emergency trip to the hospital. Advanced oversight through technology and coordinated care can result in rapid response time when an episode happens.

“At Constellation, we know that it is important to catch small changes before they become big changes,” she says. “For example, we provide urgent visits, same day. If a patient is starting to have a symptom that gets out of control or an exacerbation of a condition persists, we’ve been able to get a same-day virtual NP visit booked within an hour to resolve the situation.”

Having this responsiveness is especially helpful to clinicians. It immediately loops them into the situation and offers an “extended reach.”

Population Health in Home Care Achieves the Triple Aim

In summary, developing scalable population health solutions for in-home care is a Triple Aim necessity as it: 

  • Improves the patient experience of care (including quality and satisfaction)
  • Improves the health of populations
  • Reduces the per-capita cost of health care

Walsh explains: “Constellation has a unique model because we figured out a way to serve the patient, serve the families, and serve the primary care physicians while improving our outcomes as an agency. And ultimately that reduces cost across the board.”


Constellation Health Services is an award-winning, value-based home health care agency serving the Northeast. At Constellation, our goal is to provide a comprehensive stay-at-home health solution for your patients that includes a team of trained professionals, a suite of technology services, and coordination of in-home diagnostic and delivery services. We help partners achieve an average savings of 10% by avoiding rehospitalization penalties and reducing nursing home utilization and length-of-stay. Contact us for more details.

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